That would hardly be more disrespectful to the dead than the mind boggling recommendations released by the supposedly comprehensive Review of Maternity Services. After reviewing the dozens of preventable infant and maternal deaths, nearly all due to LACK of supervision of midwives and LACK of technological interventions, the Review recommended … wait for it … LESS supervision of midwives and LESS access to interventions!

Have these people lost their minds? No, they’re simply playing politics.

That’s right. Although the Review found babies and mothers died from the same causes over and over again: failure of midwives to appropriately classify the risk level of patients, failure of midwives to use lifesaving technology, failure of midwives to call doctors who could save babies and mothers, the main recommendation is:

All pregnant women will be provided with maternity budgets of £3,000 to pay for personal midwives and home births.

Despite the fact that dozens of perinatal and maternal deaths occurred because midwives refused to consult doctors and withheld lifesaving treatment, the UK government apparently thinks the solution is less supervision for midwives, and less access to lifesaving treatment.

Have these people lost their minds? No, they’re simply playing politics, kowtowing to the powerful midwives union (the Royal College of Midwives) and pandering to those who are looking to save money on maternity care regardless of who dies as a result.

The impetus for the Review was the Morecambe Bay report investigating a Cumbrian midwife-led hospital unit after a series of preventable perinatal and maternal deaths The report identified 16 perinatal deaths and 3 maternal deaths that had taken place in the unit as potentially preventable. The cause?

…[M]idwives took over the risk assessment process without in many cases discussing intended care with obstetricians, and we found repeated instances of women inappropriately classified as being at low risk and managed incorrectly. We also heard distressing accounts of middle-grade obstetricians being strongly discouraged from intervening (or even assessing patients) when it was clear that problems had developed in labour that required obstetric care. We heard that some midwives would “keep other people away, ‘well, we don’t need to tell the doctors, we don’t need to tell our colleagues, we don’t need to tell anybody else that this woman is in the unit, because she’s normal’”

Unfortunately, Morecambe Bay was not an isolated incident. At Royal Oldham/Greater Manchester, seven babies and three mothers died in just eight months. And at Milton Keynes:

History is repeating itself with the deaths of FIVE more newborn babies following staff failures at the hospital maternity unit…

Milton Keynes has now seen at least eight such deaths in two separate periods over the last eight years.
The latest five deaths happened over eight months between 2013 and 2014…

Most of the deaths involved staff failing to recognise or act upon warning signs of foetal distress.
All the babies were full term and previously healthy, and in each case parents claim speedier medical intervention could have saved their lives.

The Maternity Review confirmed that there is an epidemic of preventable perinatal and maternal deaths in the UK maternity care system:

Half of hospital maternity units are failing to meet basic safety standards, according to the NHS watchdog.

A total of 7 per cent have been rated ‘inadequate’ and a further 41 per cent ‘require improvement’.

NHS experts warned that at the worst units there are ‘dysfunctional relationships’ between midwives and doctors who are working in ‘silos’ – almost independently of one another.

Mothers and babies are routinely being harmed as a result of mistakes by midwives, doctors and other staff.

Although most errors are classed as ‘near misses’ or low injury, some have tragic consequences. Last year, 151 women and newborns died on maternity wards and another 351 suffered severe harm.

How would providing women with money enabling them to choose midwife led units and homebirths address these deadly mistakes? It wouldn’t and it couldn’t:

If the problem is a midwifery philosophy that privileges unmedicated vaginal birth above the lives of babies and mothers, allowing midwives more scope to excercise their personal philosophy is likely to lead to MORE mistakes and MORE deaths.

If the problem is that midwives fail to collaborate and consult with doctors, allowing more midwives to practice where doctors aren’t available is likely to lead to MORE mistakes and MORE deaths.

If the problem is that midwives are failing to use lifesaving interventions, promoting homebirth where midwives could not possibly be farther away from life saving interventions is likely to lead to MORE mistakes and MORE deaths.

No matter. The recommendations of the Review are divorced from the reality of the findings because the maternity allowance was a done deal, decided upon long before the evidence was even examined.

UK patient advocate James Titcombe, father of baby Joshua who died at Morecambe Bay specifically because midwives refuse to consult a pediatrician, was one of the original members of the Maternity Review panel. He resigned shortly after the early meetings.

I’m concerned that the review isn’t following an evidence based approach. The work looking at evidence about the current qualitify and variation in safety is only just starting (it was only instigated at all as an afterthought). Robust evidence … should surely form the starting point …

I felt that the balance of the maternity review is weighted towards the professional voice. Those who have suffered avoidable harm of loss … are not in my view properly represented and are not being heard as clearly as they should…

Sadly, the Review was a piece of political legerdemain, pretending to address the issue of safety, but actually used to promote the goals of the midwifery trade union and provide cover for efforts to cut maternity costs by forcing women out of hospitals and into homebirth.

The end result? Babies and mothers will continue to die preventable deaths in the UK maternity system because politicians are more concerned about politics than about babies lives.

The recommendations of the Maternity Review are an insult to the memories of those who died preventable deaths at the hands of the maternity system, but apparently the Review was never meant to improve maternity care.

Not all UK midwives are nurses, some UK midwives enter a midwifery program where they don’t have to be nurses first.

Sarah

Thank you Dr Amy for writing this piece. I have had 2 babies in the last 3 years in midwife-led units within a large hospital, with an operating theatre and consultant obs literally just down the hall if needed. I am terrified that current trends mean this option will be discouraged for many uk women, and am disgusted by the political stunt that this review has turned into. Respect to James titcombe for his efforts, and shame on those midwives who won’t admit that there are problems within their own ranks. Disappointingly, the UK media has reported on this report only positively, not at all critically.

Steph858

When I first saw this story, I thought it was a way for the NHS to save money by denying women pain relief: “You want an epidural? Oh, well unfortunately you already spent your £3,000 budget on ultrasounds, antenatal classes and a Rubella vaccine. Too bad.”

Allie P

The Daily Mail article claimed that “fewer than 1 in 4” women want to give birth in a hospital. THIS CANNOT BE TRUE, CAN IT? I mean, I guess if all birth centers in the UK are as appalling at Morecombe Bay, I wouldn’t want to give birth there, but the actual rate of homebirths in the US is like, less than 1%. I don’t even think 75% of Americans giving birth in the hospital want pain med free births, in the hospital.

mabelcruet

Rule no 1-don’t believe anything you read in the Daily Mail. It’s a combination of lies, half-truths and inventions. The figure they are touting is a lie-1 in 4 women would prefer to give birth in a midwife led unit, or an alongside midwife unit (one in a hospital next to the consultant led unit), or a standalone birth centre. What the Wail did was lump together everyone who said they didn’t want to give birth in a medical environment, and said that was all ‘home births’, instead of more accurately ‘not in a professorial/medical led unit’ .

AA

Here’s where I think this comes from:

The UK is set up a little differently than the US for maternity services. AMUs (alongside midwifery units) are common. An alongside midwifery unit is literally next to a hospital so it is easy to transfer a patient.

In the US, it’s pretty much “Home, hospital, or place that calls itself a birthing center that a random midwife rents”

I have been unable to ascertain the 49% of women statistic nor the 1 in 4 statistic from the National Maternity Review report.

The Review ignored a survey commissioned by the Department of Health and carried out by the Oxford perinatal unit which showed most women had choice of place of birth and that only a minority wanted homebirth or freestanding midwife units. The issue is exactly as AA says above. Alongside units (basically midwife units on hospital grounds) are very popular and the Review seems to be conflating these with community births.

Dr Kitty

NCT members are almost entirely white, middle class, crunchy and lean towards NCB/AP. They run the Childbirth classes Dara O’Briain makes fun of.
WI members are also majority white and middle class.

The surveys are definitely not representative of the wishes of *most* British women, but are representative of a vocal and privileged subset.

Sarah

Yep. Midwife led units in hospitals, adjacent to consultant led units, are very popular with British women. Freestanding midwife led units and homebirths are the pursuit of only a small minority.

CSN0116

OT: A dear friend has been bit by the woo. She is a first-time adoptive mom to a newborn baby girl (she cannot have children of her own and this adoption was so long awaited). Baby girl is thriving great on Enfamil’s Gentlease formula. But mom, who has now taken to baby wearing and other woo activities, has been bored and Googling ways to be more like her biological mom counterparts, i.e. another way to make feeding baby “fancier” in the absence of being able to breastfeed.

Her solution? She feels compelled to stop feeding Enfamil and start shipping organic formula from Europe to feed baby. She claims the ingredients are far superior. I asked if the outcomes of the kids are superior, as that’s what would matter. She had no answer.

Does anybody know anything about this form of woo? What is the preoccupation with paying hundreds of dollars a month to ship European formulas to the States?! Despite the “lack of GMOs and differently derived DHA,” in every health study I’ve ever seen, once SES is controlled for, our kids look the same as theirs. And this mom enjoys a very healthy SES! I don’t understand why she’s doing this to herself and I want to talk her off the ledge… :/

fiftyfifty1

As long as it’s an iron-containing commercial formula, I don’t fight parents about what brand they use. If they ask my opinion about organic, or importing from Europe etc., I tell them that I don’t think it’s any better, just more expensive. But otherwise I don’t try to talk them out of it. Sure they are wasting their money, but the ones asking usually have money to waste. I think it reflects their desire to distance themselves from the “low class” connotations of regular formula. Sad, but basically harmless.

AirPlant

It is sort of like how I started packing my lunch to work. I could have just bought an insulated bag or gotten a stack of brown bags, but instead I spent two days googling bento boxes before buying four from Japan and having them shipped.
My lunch is no better for being in an adorable container, it is still just a boring PB&J and fruit but it really makes a difference to me for my shitty lunch to be in attractive, reusable packaging.

CSN0116

PB&J. Yummmm. I live on that shit 😛

AirPlant

I never get tired of it, it doesn’t need refrigeration, it fills me up, and the ingredients are cheap! It is the king of lunch foods. Unfortunately in fancy Japanese bento boxes I will need to cut it into PB&J fingers, but that is a sacrifice I will make for cuteness.

mabelcruet

As an English person, I can safely say I’ve never had a PB+J sandwich! Do you use crunchy or smooth? And what sort of jelly? I take it thats jam (not wobbly gelatine jelly/jello?). Any particular flavour of jelly? Is it sweet jelly or savoury jelly like redcurrant jelly? I really want to try this now! And bread-white, brown, wholemeal, granary?

DaisyGrrl

There’s infinite variety available! I like smooth peanut butter with grape jelly on white bread, which I believe is pretty standard, but you can have it any way you like. Organic crunchy peanut butter with raspberry jam on a multi-grain artisanal bread? No problem! pick your favourite of each and go to town! Toast the bread for extra-goopy peanut butter and enjoy.

mabelcruet

First problem-Tesco doesn’t sell grape jam! The nearest is plum. Wonder if marmalade would go? I’ll need to do a few experiments I think!

AA

Strawberry jelly is the closest substitute to grape.

AirPlant

Marmalade is OMG SO GOOD. I like it with crunchy peanut butter (to play with the chewy bits in the marmalade) and a thick nut bread.

Megan

I prefer strawberry or blackberry jam with smooth PB on whole grain bread. Once you’ve tried PB&J, you can always branch out to the ever famous American fluffer nutter!!

Charybdis

Peanut butter and Karo syrup sandwiches are tasty as well. I myself prefer a straight-up peanut butter sandwich sans the jelly, but I have been known to eat peanut butter and apple jelly sandwiches. Or peanut butter and potato chip sandwiches.

Never got into the fluffernutter sandwiches (peanut butter and marshmallow creme sandwiches). Something about them just screamed “NO!”

AA

EIther crunchy or smooth is acceptable. Grape jelly is the traditional standard, but people use a variety of flavors (I’d say strawberry is second). Marmalade never. Savory never.

In the US, I think brown/wholemeal/granary are all lumped in the same category. I actually had to google granary.

The most traditional of traditional PB&Js is cheap white bread, peanut butter (not the kind that must be refrigerated), and grape jelly.

Nick Sanders

Crunchy or smooth is a matter of personal preference and unending debate. You can use just about any kind of jam, although I wouldn’t suggest marmalade, I don’t think the zest strips would go well with the peanut butter. Personally, I’m partial to strawberry preserves (American jams are divided into three broad categories: “jelly” is made from strained fruit juice, “jam” uses the entire edible portion of the fruit rendered to a fine pulp, and “preserves” is a mixture of pulp and fruit chunks) and guava jelly. White bread is my personal preference, since this sandwich will stick to your mouth and need to be washed down with copious quantities of cold milk, and coarser breads just intensify that. Although other people are saying the tradition is cheap white bread (and it kinda is) I prefer the higher quality ones, or other smooth, soft breads such as golden potato or oatmeal. I think a clean, soft texture through the whole sandwich really improves the experience.

Other nice jellies to try are stone fruit jellies such as apricot and mango. Their bright, sweet flavors make for an interesting contrast with peanut butter’s heavy creaminess. And you pretty much cannot go wrong with tart berry jellies: raspberry, blackberry, blueberry, elderberry, boysenberry… they’re all delightful.

AirPlant

My daily sandwich is smooth peanut butter with blackberry jam on trader joes million grain bread. I have no preference on the peanut butter really, but I am pretty adamant about the blackberry jam and the nut bread. I grew up with a pretty crunchy mom and we were not allowed store jam or white bread and so now the super sweet grape jam and the weird sponginess of white bread just doesn’t taste right to me.
I am also a pretty big fan or peanut butter and honey, but only made the night ahead. The honey kind of solidifies over night and turns crunchy and I like the texture.
Less traditional, my friend likes to make grilled peanut butter and jelly sandwiches and they are just the absolute best. You make the sandwich, butter the outside and grill it like a grilled cheese and the inside gets super gooey and it is like delicious dinner magic.

momofone

A friend of mine’s mother taught her growing up “the whiter the bread, the sooner you’re dead.”

demodocus

Jam, jelly, preserves, and marmelade are all jams. Jello is the wobbly gelatine dessert. Marmelade is mostly used for oranges. A rough guide for the other 3 that my mom taught me (so in Yankee dialect) is jelly’s the smoothest, jam has some small bits like raspberry seeds, and preserves has large bits of fruit.
i prefer white for pb&js, but mostly use whole wheat since i prefer whole wheat for all the other kinds of sandwiches. Normally i’m fairly catholic about the jelly, but right now it *must be CHERRY or GRAPE raarr!* (pregnant much?) Grape is the tradional kids’ version in my region

CSN0116

Yes, she is certainly using this as a way to make herself feel superior about having to formula feed. And not in some snobby way – she’s a doll. But she comes from a social class where feeding is very moralized. And despite being educated and rational, in general, she is desperately trying to “make up” for her limitations as an adoptive mom. And I want her to stop that >.< haha.

I just don't like the idea of dicking around with a baby who has already had two formula changes, who is now thriving/eating/sleeping/pooping AMAZINGLY- for the sake of experimental superiority and woo.

Where is this literature claiming that Holle is better than Enfamil, for instance? All I find for evidence is blogging and some thread in (literally) and "crunchy moms" group.

fiftyfifty1

“I just don’t like the idea of dicking around with a baby who has already had two formula changes, ”

Well, the baby at least is something you don’t need to worry about. One of the biggest myths out there is that it is somehow hard on a baby to switch formulas. Unless it has allergies or other severe intolerances (very rare), a thriving baby will thrive just as well on a different brand.

CSN0116

When Target ran out of my my beloved generic Enfamil and I had to temporarily buy name brand, my baby was so fussy and pooped like crazy. Perhaps that was because I couldn’t transition slowly, but I have always heard that abrupt changes, even within brands, can be disruptive. But alas, you’re right. The baby is not mine to worry about and she will be ok 😉

Daleth

I just don’t like the idea of dicking around with a baby who has already had two formula changes, who is now thriving/eating/sleeping/pooping AMAZINGLY- for the sake of experimental superiority and woo.

Can I ask, how is this your business? Why does it matter to you?

CSN0116

It’s not. It only ever became “my business” (and I don’t mean that officially) because she came to me with this idea and asked for feedback. I’ve never heard of such a thing and I see her struggling in a lot of ways right now — this is complicating her struggle. Sorry, just anonymously sharing thoughts here and inquiring :/ not things I’d ever speak aloud to my friend.

The Bofa on the Sofa

I think it reflects their desire to distance themselves from the “low class” connotations of regular formula. Sad, but basically harmless.

I don’t think perpetuating that stereotype is harmless. Healthwise, it’s not a problem, but there is societal harm.

fiftyfifty1

“I don’t think perpetuating that stereotype is harmless. Healthwise, it’s not a problem, but there is societal harm.”

Stereotypes about formulas are harmful, sure. But how would browbeating my patients about choice of a formula brand help matters? To insert yourself into a private parenting decision, as long as it’s not dangerous, is disrespectful and often counterproductive even if your intentions are good. Parents are the parents and get to make the parenting decisions as long as what they are doing is not dangerous. There are much bigger fish to fry.

The Bofa on the Sofa

But on behalf of your other patients who get stigmatized with the “low class” connotations? Isn’t it disrespectful to them to let such stereotypes perpetuate?

fiftyfifty1

Seriously? I’m supposed to continually harp on my patients who use organic or European formula until they switch to regular commercial formula because it’s my duty to my other patients who can only afford the regular? You seriously think this would be effective? You seriously think it’s a good use of my Well Child Check time?

Megan

OK, I’ll admit it. Holle formula is actually what we used. It was the only formula we tried that gave us easy poops and no gas. Honestly, it cost me no more than getting a brand name formula here in the US, even with shipping (though I’m sure it’s more expensive than generic), but to get that price I just had to plan and order a month or two in advance. We had such a good experience with it that I will use it again. If that makes me a mom looking to find a way to feel superior, than so be it. My kid could poop, didn’t have gas, she loved the taste and she was happy (and that made me happy).

CSN0116

I’m not judging you 🙂 It sounds like you were searching for a formula to make your baby happy and you found it. I get it. However, my friend’s baby is doing amazing on the Gentlease (after a couple switches) and mom was so content with things the way they were… until she got to Googling. For her this is more of a process like the poster below describes – to feel superior about her “choice” (which not BF wasn’t a choice for her, she’s an adoptive mom). But she comes from a social circle that moralizes the shit out of the way a baby is fed so…

I feel bad that she feels the need to behave this way 🙁 She’s a great mom and baby is thriving. She’s only screwing with it because of woo, not for reasons like yours. I want to save her lol.

Megan

As an adopted kid who is now an adult, I can easily see how adoptive moms could fall victim to woo-shaming (not sure what else to call it) in this NCB/AP/BF-til-death climate we are in currently. I think the best thing you can do for her is just repeatedly encourage her than being an adoptive mom fills all the roles baby needs regardless of how she got her baby or how she feeds her baby. If babywearing makes her feel close to her child, I wouldn’t disparage it (that’s another thing I’ll admit I did and loved too) and if she really feels better about feeding her baby a different formula I’m not sure I’d press too hard with that either. I agree with you it’s not the best idea to switch formula if something is working, and that may be a better angle to approach it from rather than just arguing the finer points of the formula composition. But that being said, I can really appreciate how adoptive moms must feel. I think even in the 80’s when the parenting climate was different, my parents had moments where they felt the need to be reassured that they were “real” parents too.
I think we just need to be careful in which battles we choose to fight and instead look at why the person is making the choice and see if we can help them with the real causative issue. It sounds like your friend might be feeling some (obviously unwarranted) inadequacy as an adoptive mom and hanging around crunchy blogs/online boards probably exacerbates that. I think the best thing you can do is be a counter point and remind her often how special her relationship with her child is and what really matters most about being a parent. Remind her that she has a beautiful thriving child who was given a great life because of her and her family and that one day her child will not give a crap how she was fed but will be immensely thankful to have been given a great life with a great, obviously caring mom.

CSN0116

Thank you so much! Very well said 🙂

Inmara

In the beginning we tried Holle too (because organic! and in EU it really means something, it’s very strictly controlled designation and appeals to me due to environmental concerns). However, I suspected that baby gets gassy from cow milk and we switched to Nanny Care – goat milk based formula from New Zealand. Now talk about carbon footprint and shipping costs from NZ to Europe! Ironically, other goat milk formula available here is produced in Netherlands but costs the same.

The Bofa on the Sofa

I think you have just found perhaps the best example ever of “First world problems”

Allie P

Awww, I like my baby sling. It’s not woo-y. It makes her happy and not crying to be held, and it leaves my hands free to you know, DO stuff. Like grocery shop. Or chase my other kid.

I also use enfamil.

CSN0116

I “wear” too, on occasion LOL. I’m speaking in reference to one part of a giant psychological process/breakdown dear friend is currently experiencing, one being perpetrated by real life and online woo people.

demodocus

If that’s as far as it goes, i’d just shrug and ponder the idiosyncracies of those wealthy enough to import fancy French food (or whatever) for their babies.

Daleth

*Raises hand* We used Holle formula from Europe too. We would have used organic Similac but were not into it because it uses actual sugar (as in cane sugar) rather than more milk-like and expensive things (lactose…). Also, we tried organic Similac–switching from regular Similac–and it made our babies utterly miserable with gas, etc. We never had ANY issues at all with Holle; they loved it and did wonderfully on it, going from like 40-somethingth percentile in height/weight to 90+ height/70+ weight.

And “organic” actually means something in Europe.

And as Megan says below, getting Holle from Europe costs about the same as using a name-brand formula in the US. It’s not that expensive.

Hilary

When I was researching formula there were many, many articles/forums advising people to import from Europe. There was so much negativity about all the American formulas, I completely understand why your friend feels she needs to get the European ones. We ended up going with regular Similac and he’s done just fine with it. I don’t suppose there’s any harm in importing formula from a trusted supplier if you have the money to do it.

CSN0116

Thanks for the insight! The “crunchy mom” site (literally named that) said that after donor breast milk, imported formula was best 😉

mabelcruet

For UK people-did anyone else hear ‘You and Yours’ on BBC Radio 4 on Tuesday 23rd Feb? Its available on their podcast. It was a call in programme about maternity choices and they had Cathy Warwick on (president of the Royal College of Midwives, the person who appointed Sheena ‘dead babies are boring’ Byrom to join the council).

Anyway, Ms Warwick did a very gentle and really quite persuasive interview about personalised care, and how midwives really TRULY listened to women. And then the phone-ins started. Woman after woman called in saying that they had been upset by what a midwife had told them during their labour (things like ‘you must be so disappointed you didn’t have a real birth (when they delivered by section)), and how they felt personally insulted when it was implied that their baby’s birth wasn’t natural or that their baby was second-class or abnormal in some way because of the way he entered the world.

And to every caller Ms Warwick’s response was the same: that midwife wasn’t acting professionally, she must be a bad apple, she had the wrong attitude, we aren’t all like that, her views need to be challenged etc. Except it was every caller-how many bad apples out there? How many midwives with the wrong attitude? How many midwives not supporting the women and families?

I know a lot of midwives-I know they struggle with workload, I know they are angry at what they see as cost cutting and I know they are upset that they physically cannot provide the time and care that each individual woman needs because they are expected to cover too many women during a shift and spend time constantly trying to catch up. These women are being let down by their own College, by their own establishment, which seems to be over run by a group of people who despise evidence-based care, ignore what women actually want, and insist that they know best because they are the professionals. They are far more paternalitistic than any doctor I have ever meet, but because this is cloaked by pseudo-caring, sanctimonious mother-earth-goddess, woo-infested, ‘feel the love and womyn-power’ and the ‘power of the all-important yoni’ belief system they seem to think they are somehow speaking for the mothers. Complete self-delusion.

AirPlant

Sometimes I think the best part of being a woman is the sheer number of randos who feel like they can speak for me…

I did. When I last looked at it the comments were so depressing I stopped reading them.

Dr Kitty

I give up on Guardian readers and childbirth.
The NCB doctrine and woo is strong, and almost none of them have enough science background to evaluate evidence.
They’re also absolutely convinced that they are right.

Megan

I see our “friend” sabelmouse is there with the usual anti-vax nonsense too.

Amy Tuteur, MD

A meme:

Megan

So, if a woman uses her money to go to a home birth midwife, are they still covered by the NHS for damages if something happens to them or their baby? Are home birth midwives integrated into the NHS system? If not, I could see that being a convenient way to get women to deliver their babies out of a hospital under the guise of “their choice.” I admit, I am not very familiar with the NHS so this could all be speculation.

Hannah

It’s not being framed as specifically for home births, but besides from the obvious benefits for the more “radical” midwives doing there own thing, there’s an agenda for personal healthcare budgets right up to the level of the chief exec of NHS England:

It’s about breaking up the NHS as an organisation and creating more opportunities private sector groups to get a piece of the pie.

Hilary

Some of the Republican candidates in the U.S. are proposing something similar. If it happens, those of us with more intensive and expensive medical needs (in my case, my son) will be seriously and badly screwed.

fiftyfifty1

“All pregnant women will be provided with maternity budgets of £3,000 to pay for personal midwives and home births.”

So they are bribing women to choose homebirth with a midwife?! Am I understanding this correctly?!

Hannah

It’s not specifically for homebirths but see my post below.

Dr Kitty

Not really.
The women aren’t getting the money.
They are essentially being told “you can have a hospital birth OR you can have a homebirth/MLU birth and because they are cheaper you can also have X amount of other things from this menu of options”.

Everyone still has the option on hospital birth, NHS parenting and childbirth classes, paying out of pocket for whatever woo thing they want (reflexology, aromatherapy etc).

In reality, it will mean that the hospital safety net is being defunded further, because the money is travelling with the patients and the envelope is not getting bigger.

If you’ve spent your money on hypnotherapy and childbirth classes but end up with a PPH and need to go to theatre, that won’t come out of YOUR budget, but the hospital won’t have got the money for your antenatal care and delivery either.

So…my vote is that this is softening up the system for privatisation by silo-img off the profitable cases (which I am against), while superficially appealing to patients (choice, autonomy) and midwives (power, control).

Allie P

If they say all women get 3k to give to a midwife or other things, won’t all midwives instantly raise their prices to 3k? That’s how it works here.

Dr Kitty

As I understand it, money isn’t going to pay Independent (private) MW, it is going to be used to commission and pay for NHS MWs, who get paid according to nationally agreed contracts, so, no.

BeatriceC

OT question for the OB/GYN’s on the board. How long is “too long” for a period to last. Say a 40yo woman started her period on Jan. 14th. It was heavy for 6 days, medium for two days, then very light but consistent enough to need a pad until February 21, then on the 22nd it’s extremely heavy again and passing fist sized clots. There’s no chance the woman could be pregnant because for other reasons she and her partner have been celibate since before the January period.

Who?

You know the answer.

I’ve had a couple of ovarian cancer scares in my world in the last six months, one a very near run thing. Mind you my group is early fifties, not early forties, but still.

Changes=get a checkup.

demodocus

i know my mother had near continous ones for several years during menopause. Just wonky genetics. Definitely check with your doc, though

Who?

How miserable. There’s a lot that can be done these days to help out with those things, or so I’m told.

demodocus

Her gyn was going to give her a (much wanted) hysterectomy, but the damn thing just never stopped long enough. It’d slow to a trickle, maybe stop for several days…

Hannah

I think the same thing happened to my Mum. Things can go a bit haywire around that time.

BeatriceC

It’ll be interesting to see what happens with me, though I’m at least a decade away from menopause. I don’t have any family history to go by. My mother, all of her sisters and both of my grandmothers (my father doesn’t have any sisters) had hysterectomies by the time they were 35, so I have no clue what the family history is here. Heck, two of my three adult sisters have already had complete or partial hysterectomies, so even in my generation I don’t have any real clues. One of those sisters is older, the other is younger. The third adult sister is much younger (still in her 20’s) and adopted, though adopted from a blood relative. I think both of my female cousins who are older than I am still have their parts, but I don’t know for sure. I’ve never been particularly close to my extended family.

BeatriceC

That’s what my friend is blowing it off too, but between 40 being a little on the young side for those changes and the fact that it was pretty sudden, I’m worried enough to enlist a bunch of internet strangers to help me convince her it really is time to see a doctor. She’s a bit afraid of doctors, so it’s a tough sell.

Roadstergal

She sounds like my husband, preferring to wait it out and hope it goes away rather than face potentially bad news.

I’m of the ‘if it’s really nothing, you will be reassured, and if it’s something, better to know sooner’ mindset, but it’s a hard sell.

BeatriceC

I think that’s pretty much exactly what it is, and I think like you do. I got a little freaked out during a span of a couple months in my early 30’s when my cycles bobbled just a little bit. I made an appointment anyway, just in case. Everything turned out to be fine, and after about 6 months of slightly longer or shorter cycles than I’m accustomed to, they worked themselves back to what’s normal for me.

demodocus

Some women do start menopause that early; a friend started at 36. Still, it’s unusual thus best to check. ‘Cause it could be something *much* worse.

demodocus

Mom got it checked out and she was in her mid 40s. Hopefully, she’s right, but some things are better to be sure about. Thus why i just had an echocardiogram. Just what every sore-boobed pregnant lady wants to do. (Tech said my heart looked good, so maybe growing this one is just that exhausting?)

Who?

Glad it went well. Building new humans is exhausting.

Take it easy.

Kelly

My mom did too and she had to get on birth control to regulate them until she finally was done with menopause.

Kesiana

Huh. Did the BC make her other symptoms less awful, too? I have a decade or two before menopause, but what I remember about puberty sucked enough… and this sounds even WORSE.

Kelly

She just was bleeding for months on end and so they put her on birth control and she was back to normal in terms of periods. I will have to talk to her and find out everything that went on but she is through menopause now and not on birth control any more. I am not too excited about that part either.

fiftyfifty1

Not normal. Have her make an appointment ASAP.

BeatriceC

Thank you for everybody who answered. I can’t reply to everybody. Well, I can, but it would be annoying. To be clear, it’s not me. It’s a friend I’m trying to convince to go see a doctor who keeps coming back with “it’s probably just wonky cycles from pre menopause”. My cycles, while not textbook (21 day cycles with 2.5 days of active bleeding) are regular enough to set a watch by. It’s been that way since my cycles started and I can predict when they will start within a couple hours.

I was hoping y’alls responses would be exactly what they were so I can say “see! A bunch of people who, after reading their posts for long enough I don’t doubt their qualifications say the right thing to do is to see your doctor!”

Who?

It’s hard when you’re scared of the doc. Maybe suggest she set herself a time limit, say another month, or two weeks even, and go then if things aren’t 100% right. And in the meantime an ‘If X happens, I’ll go straightaway’ rule.

That little bit of control might help her feel better about the decision.

fiftyfifty1

That “X” has already happened.

Who?

True-but if it gets them to the door in a timeframe, I’ll take it.

The Computer Ate My Nym

She needs to get it checked. It COULD just be the first signs of perimenopause, but even if it is she needs to get her iron level checked with that much bleeding. But there are multiple other potential issues including thyroid problems, other hormonal problems, and worst case scenario uterine cancer. If it is the last, the sooner she knows, the better the probability of cure. Even if it’s “just” perimenopause, 40 is pretty early for it and secondary causes of premature ovarian failure should be ruled out. I’m also not entirely sure you can rule out pregnancy if her and her partner were sexually active in, say, December.

You mention below that she’s a little afraid of the doctor. Is it a specific fear (i.e. of a certain diagnosis, of a certain procedure, etc) or a more general fear of doctors and the medical system? Would she be willing to take anxiety medication if she could get some prescribed? (Of course, that would mean a visit to the doctor to get the anxiety diagnosed…arrgh!)

Wombat

I was the opposite end of the spectrum (my first period was basically a non-stop affair, I don’t even remember for how long – I know I hid it from my mom for a bit because I was a dumb preeteen – must’ve killed some braincells from blood loss) and I’m not a doctor, plus I think you’ve gotten your good advice… BUT I just wanted to say to your friend that I totally sympathize with how scary something so strange can be. You don’t even know how to begin to address it, so you just give up and hope it goes away. Unfortunately that isn’t always the case. It’ll ultimately feel less scary knowing it’s actually nothing, for sure, and having any avaialble help to manage they symptoms available to you. Getting to that point might suck (says 13 year old past me getting my first gyno visit – from the man who delivered me for an extra dose of weird) absolute monkey teats (depression and motivation issues me still agrees with that one) but in the end it’s worth it. Hugs and support to her for her doctor trip! <3

Jo March

OT: is anyone following the CPM bill (house bill 1162) that’s up for a vote in South Dakota? All my friends who live there are crunchy-ish, so I’ve only been hearing support for it. Currently, CPMs are illegal, and there are a few CNMs who do homebirth. Being sparsely populated, much of,the state is well over 30 minutes from a hospital and even further from a place with truly top-level care. It appears from a quick skin of the bill that CPMs won’t be limited to low-risk care as long as they get “informed consent” and the proposed midwifery advisory board will be composed of three CPMs, one CNM, and one person who has had a homebirth.

Amazed

OT: Last week at the hairdresser’s, a mother was giving advice what to do when you don’t have a babysitter: take the kid along wherever you’re going. That’s what she did. Example: she took the kid as it was quarantined with scarlet fever at the same hairdresser’s last month. The moment she decided he was healthy, she was dragging him along everywhere. The hairdresser (a former kindergarted teacher) only stared. Someone asked what she’d do if the kid has, say, chickenpox. Her reply? “Well, everyone should go through it anyway!” Err, I’d rather decide when I have it, thankyouverymuch.

demodocus

Scarlet fever. If I’d overheard that, i’d have gone into a rant. Chances are fairly good, though, that I wouldn’t have if hairdryers were on. Because of my bout with scarlet fever.

Gatita

🙁

Amazed

Demo, you’re hearing-impaired because of scarlet fever? Somehow, I missed that. I mean, I knew you were this impaired but not what you owed it to. It’s bad enough to know that there are people like you who struggle with that. To have it happen because someone was bored entertaining her recovering child at home so she unleashed him onto the public is maddening.

demodocus

So they told me. Between the hearing impairment (which could be a lot worse, so I feel pretty lucky) and the spousal unit’s probable congenital rubella, we have strong opinions on vaccines. We’re all UTD, boosters, flu, and all. Not much you can do about SF, of course, but acting like it’s just another cold is just wrong. Even colds can go bad.

Amazed

Personally, I think SF brings even more responsibility. It isn’t like tuberculosis (unfortunately, it’s still a deal here, although a much, MUCH lesser one than it was a hundred of years ago) where you can at least assume people you came into contact with have been vaccinated. THERE IS NO VACCINE FOR SF! FFS, keep your kid home!!! Even if he or she is on the way to recovery.

Funny thing is, she followed her doctor’s recommendations to a T… when it came to her own kid’s health. Once he was fine, she decided that the doctor’s opinion didn’t matter anymore. Of course, by then she only risked OTHER people’s health.

demodocus

Exactly.

SporkParade

Actually, there is a vaccine for scarlet fever. It’s just that antibiotics are pretty effective for treating it, so no one uses the vaccine anymore.

Amazed

Thanks! I had no idea.
Still doesn’t change the premise that when a kid is quarantined, you keep them home. Or… not, as it happens.

meglo91

My grandmother died probably a decade or so earlier than she should have because of scarlet fever. She had it as a kid and got a cardiac infection which caused scarring. When she was in her 40s she had a massive heart attack and my 12 year old mother stayed home from school and nursed her. Grandma lived to be 72, but the heart damage got her in the end.
I want to throttle the hair salon mom.

Dr Kitty

FYI: Current UK guidance is that if someone has had 24hrs of antibiotics for scarlet fever (which is a strep infection) then they are no longer infectious and as long as they feel well enough, they do not need to be quarantined further.

Chicken pox is contagious from 24-48 hours before the rash appears until every lesion is dried up and crusted over ( 7-10 days after the rash appears). Most kids who get chicken pox get it from someone who doesn’t have a rash yet.

Amazed

Good to know there was no danger! But it has nothing to do with what I witnessed – total lack of consideration for anyone else. Here, in this part of Eastern Europe, the standard is that there is a quarantine. Good or bad, it is there. It varies from a day to a week or even 10 days, I think. This mom didn’t break it because she knew that elsewhere, the standard was different. She just wanted to go on with her own life and she figured that everyone has had or will have those childhood diseases, so it was no biggie. She said it. She would have done the same if it was chicken pox. It’s just blatant lack of thought about other people.

Do you vax against tuberculosis in the UK? I ask because I once had a conversation with someone who insisted that this vax was totally unneeded because they didn’t give it in the USA or France, or somewhere like this. Totally refused to consider the fact that we’re still the champion in the tuberculosis department in Europe and no, by that I don’t mean the champion in defeating it.

Dr Kitty

The U.K. stopped routine childhood BCG vaccination a few years ago.
However, vaccination is still offered at birth for babies if their parents or grandparents are from a TB endemic region and by occupational health for healthcare workers etc.

Amazed

Thanks! What can I say, still waiting for the moment when it won’t be needed routinely here as well.

Tiffany Aching

I live in France and tuberculosis vaccination is routinely done in at risk areas (Paris and its region is amongst them), where it can be mandatory to put you child in daycare.

Amazed

I can’t believe it.

Listen, UK, I can see you want to provide your midwives with something to do instead of having them go unemployed or, God forbid, pour moeney into educating them to fill the obvious gaps, but we’re talking about lives.

Where is the money meant to reorganize the system so that the midwives leading those births that you’ll so kindly finance won’t start fucking up even more? Seems a buit unfair, hmm?

I certainly hope that if smaller hospital maternity units close, women won’t choose to have their babies at home but go to the nearest bigger hospital unit. Of course, that’ll be a strain on them. Not a great thinker, are you, Baroness?

mabelcruet

Just had a look over at Twitter. As expected, poor James titcombe is being lambasted again for pointing out that the evidence base for homebirth safety isn’t that good. Still waiting for Sheena ‘stop talking about dead babies, James, it’s boring now’ Byrom to start up.

Amazed

She will. Now that she has the support of the system as this recommendation made clear, she won’t miss on this chance.

Midwives and doctors attending courses to avoid “dysfunctional realtionships”. Barf. Save the money and just make it clear to the freaking midwives that the first one who impedes treatment is out of job and not likely to find another. Then follow it with an action. I guarantee it’ll have a better effect in a shorter time.

They’re beside themselves trying not to say that their precious, money-saving midwives bear the huge part of the blame.

Kelly

He and his family have so much respect from me. They have been to hell and back with not only dealing with the death of their son but with the public fight they have had to endure. I am one of those people who crumble under this kind of pressure. I am deeply saddened that their crusade did not bring about the changes they were hoping for. I hope at some point they will be able to terms with everything that has happened. Those women are vile. I still can’t believe that they are able to get away with the crap that they have pulled. James Titcombe has been nothing but professional in his crusade. They are like teenagers seeking their revenge.

Then again, thinking it through, it probably will save NHS money in the long run. After all, killing a baby outright means the parents only receive a tiny amount of compensation. Leaving the baby alive but with devastating brain damage-the parents get millions. So to save money, let’s all deliver at home and do a population cull.

(I’m being sarcastic)

As a pathologist, this will undoubtedly increase my workload.

AA

Note that the maternity report indicates an increasing number of women with complex medical histories while pregnant.

…Then it goes into the importance of being able to choose an intended place of birth, such as out of hospital birth.

Yeah, that goes together.

Gene

I don’t know… There are many subtle injuries than can result from hypoxia that may not be evident right away. Learning disabilities don’t often manifest until school age.

There is a veritable truckload of bullshit in science.¹ When I say bullshit, I mean arguments, data, publications, or even the official policies of scientific organizations that give every impression of being perfectly reasonable — of being well-supported by the highest quality of evidence, and so forth — but which don’t hold up when you scrutinize the details. Bullshit has the veneer of truth-like plausibility. It looks good. It sounds right. But when you get right down to it, it stinks.

There are many ways to produce scientific bullshit. One way is to assert that something has been “proven,” “shown,” or “found” and then cite, in support of this assertion, a study that has actually been heavily critiqued (fairly and in good faith, let us say, although that is not always the case, as we soon shall see) without acknowledging any of the published criticisms of the study or otherwise grappling with its inherent limitations.

Another way is to refer to evidence as being of “high quality” simply because it comes from an in-principle relatively strong study design, like a randomized control trial, without checking the specific materials that were used in the study to confirm that they were fit for purpose. There is also the problem of taking data that were generated in one environment and applying them to a completely different environment (without showing, or in some cases even attempting to show, that the two environments are analogous in the right way). There are other examples I have explored in other contexts, and many of them are fairly well-known.

But there is one example I have only recently come across, and of which I have not yet seen any serious discussion. I am referring to a certain sustained, long-term publication strategy, apparently deliberately carried out (although motivations can be hard to pin down), that results in a stupefying, and in my view dangerous, paper-pile of scientific bullshit. It can be hard to detect, at first, with an untrained eye—you have to know your specific area of research extremely well to begin to see it—but once you do catch on, it becomes impossible to un-see.

I don’t know what to call this insidious tactic (although I will describe it in just a moment). But I can identify its end result, which I suspect researchers of every stripe will be able to recognize from their own sub-disciplines: it is the hyper-partisan and polarized, but by all outward appearances, dispassionate and objective, “systematic review” of a controversial subject.

DiomedesV

Thanks for posting. I have a file of papers in my paper database labeled “Bullshit” because of just this.

Charybdis

From http://www.dailymail.co.uk/news:
“They will be told about their maternity budgets during their first check-up with the midwife or GP after discovering they are pregnant.

Those considered low risk will be offered 3000 pounds but there will be more for those with complications such as obesity, long-term illnesses or who are expecting twins. Some may opt to pay for their own one-to-one midwife to enable them to have a home birth. Others may put it towards having their babies delivered in a private suite at a midwife-led centre where they can have hypnotherapy, aromatherapy and acupuncture.

Some may opt to pay for home visits from midwives after the birth or breastfeeding classes.

Official expect the budgets to be available to all women by 2018/19. They will still be allowed to turn the money down and have a hospital birth if they wish.

…Baroness Cumberlege, a former health minister, said: “Women are not getting the choices they want. This is going to give women much more clout. It’s a driver for change, it’s a driver for choice.”

I can’t even begin to start to understand the so-called thought process here. Hypnotherapy? Aromatherapy??! Acupuncture!??!! What the actual F*CK?

AirPlant

Congrats! You are AMA with triplets! Have $6000 for aromatherapy, that will for sure make things safer!

Roadstergal

You rock that HBA3C, mama.

How much does one of those inflatable pools cost?

AirPlant

Just because you almost bled out the last two times doesn’t mean this time won’t be different. If you do it in water you can hardly even tell, which is the best possible argument for a home birth!

mabelcruet

If they don’t get a live baby at the end, do they have to give the money back? And if the place of birth has to change as an emergency , which I suspect will happen, do the midwives or the standalone unit have to hand the fee over to the local NHS hospital that stepped in and dealt with the fallout and tidied up the mess, like NHS has to do a lot with private providers?

Charybdis

That’s a damn good question. I don’t know.

AA

I wasn’t able to find a source from the NHS re: additional money for expectant mothers with a more complex medical history, such as obesity. Anyone have a source?

Right, but where did DM get their information? DM is not the original source of…well…nearly anything. I am unable to locate the original source of this claim. The PDF on NHS’s website does not mention this.

Lizzie Dee

Given the way politics is ordered here, the Daily Mail story is probably largely the point. Don’t think anyone has actually got round to realising that this is unworkable.

MaineJen

I can’t even. At least there is an option to have a hospital birth if you want to.

Sarah

Since apparently one can still have a hospital birth anyway, and nobody’s getting turned away if they rock up in sufficiently established labour (car park stories aside) I’m not sure what’s to stop us spending 3k on as much pregnancy scanning and aromatherapy as we like, then having a hospital birth regardless?

Madtowngirl

Not to mention the fact that “low-risk” means very little when it comes to the actual delivery. This blog and its comments are full of stories of low-risk turning high-risk in a matter of seconds.

Roadstergal

Give more money to fund a home birth to the women who specifically had to be excluded from the Birthplace study results to keep home birth from looking too awful.

Did this Royal Midwives Union become so powerful because they offer births at a lower price? Or for some other reason(s)?

Socialized health care scares the shit out of me… even though I’m told it’s what we should want here in the US and we suck for not having it :/ Seems nobody has a good system for delivering health care.

AA

I wonder if it’s because the care of pregnant women and postpartum women is mostly via midwives, as opposed to the USA.

In the USA, you have registered nurses, midlevels, technicians, nursing assistants, and physicians.

In the UK, it seems to be midwives, physicians, and maternity techs.

CSN0116

Ahhh, thank you!

AA

Keep in mind that the UK system makes it even more bizarre that some midwives are obsessed with being “guardians of normal birth” and lauding themselves as “experts in normality”

The RCM explicitly wishes to increase the number of women who have
“normal births” Normal births defined as “without induction, caesarean,
instrumental
delivery or episiotomy, but including epidurals and other anaesthetic”

A midwife is involved in the medical care of ALL UK maternity patients, from the healthiest to the most medically complex. In the US, a CNM could transfer all care to physicians and nursing staff.

What nursing staff would ever say that they are the “guardians of normal [insert whatever]”? A nurse will say they provide the very best care to their patients. Bullcrap with being experts at the “normal” ones. Can you imagine a nurse interviewing for a med-surg job? “I consider myself an expert on normal nursing”

Dr Kitty

“Normal birth” should not be the goal.
Healthy mothers and babies who are happy with the care they received is the goal.

Anyway, with more evidence that induction prior to 40w has better outcomes for all of the demographics that are increasing in size ( diabetics, AMA, high BMI, multiple pregnancy) I don’t know how they plan to achieve that goal.

If the evidence says that INCREASING induction rates (and therefore DECREASING normal birth rates) is in the best interest of women and babies, why is increasing normal birth rates the goal?

Their party line speaks to our own prejudices I think. An ideal woman doesn’t complain or show weakness, she just gets on with the business of doing what needs to be done without asking for help or resources.
Even with a major medical event like birth I think the little voice of our cultural prejudices whispers in the back of our minds that there is no reason that a woman should need that much fuss made, especially over something that women can do without issue most of the time. It isn’t that we think women’s lives are expendable, just that we think that we shouldn’t have to care about or invest in the work of keeping her alive.

Gatita

Don’t look at the UK, look at other countries where socialized medicine works well.

Sarah

I have many issues with maternity and obstetric care in the UK at the moment, as well documented in the comments section here, but the NHS does a pretty decent job overall. Works pretty well for the money we spend on it.

Gatita

I’m sour on it right now because I know someone whose preemie died recently because he wasn’t tested for GBS. But I know someone else with a chronic illness who loves the NHS so maybe it’s just maternity care that’s the problem.

Erin

My father’s cancer care from his GP correctly interpreting his fairly vague symptoms through his treatment so far plus support has been stellar. Everyone involved from the consultants to the cleaners have been wonderful. On the other hand my maternity experience was hellish, endangered both my life and that of my son and then was compounded post natally by either malicious or stupid midwives …. (apparently he didn’t descend because my vagina was too traumatised by unprocessed rape trauma) to the point that I was diagnosed with Ptsd when he was 7 weeks old. Like everything else I think it comes down to who you get..same you cant spend the money on “restraining orders” for certain members of staff.

demodocus

and that “get out before i use the IV stand/bedpan/my husband’s white cane on you” would probably cause more trouble than the brief satisfaction

Dr Kitty

Erin, you CAN say that due to a breakdown in trust with an individual or individuals, you are unwilling to be treated by them as you feel that the therapeutic relationship has become damaged beyond repair as you have no faith in their ability to work in your best interest, preferably in writing.

Barring life or death emergencies when no other warm body can be found, that should be enough to get them off your case.

Hilary

Unfortunately these things happen everywhere. I’m so sorry for your friend, that is heartbreaking.

Maternity care, in England specifically, is an omnishambles.
Maternity care in NI, Scotland and Wales is different, and appears to be better.
As I’ve said, locally there is little will to push homebirths and all the MLUs are under utilised. Very different to England.

The NHS is, no doubt, over managed, overly fragmented and held together in places with goodwill, cups of tea and sheer bloody mindedness, but it does work, for the most part, very, very well.

My practice gets about £140 per patient, per year. That is it, that is our incomings. That gets you unlimited consultations, prescriptions, home visits, referrals, blood tests, ECGs etc. The average person in Northern Ireland sees their GP six (!!!) times a year. I’m very good value for money.

Who?

How do you keep the lights on?

Dr Kitty

No idea.
That is why we have a practice manager and an accountant.

Inmara

Do you have any kind of limits as for how much referrals and tests GP can write per year? It’s the curse of our healthcare system – GPs have a set “quota” per count of patients and if they go over it they get reprimanded. Similarly, there are limits of how many people can get particular healthcare services (doctors visits etc.) in given month and as a result if you want to get free service it will be available after 6 months or so (paying out of pocket or from private insurance – welcome next week). Just read an article about elderly woman who got breast cancer and mastectomy because she had to wait for necessary tests almost a year and thus didn’t catch it earlier. It’s really frustrating to pay high taxes but not be able to get promised free healthcare when you need it most.

Dr Kitty

No. I can refer, test or prescribe as much or as little as I feel clinically appropriate.

The practice has a drugs budget, but if we overspend, as long as we are meeting certain targets (high percentage of generic prescribing, lower cost drugs prescribed first line etc) there isn’t an issue, and on a day to day basis cost doesn’t factor into my decision making. If someone needs an expensive drug that is what they need.

For example, I know of a small practice that has a large, extended family on their list, many of whom suffer from the same serious genetic disease, so 1% of their practice list is on drugs which cost thousands of pounds a year for each patient. The system recognises that things like that happen, so there are no penalties for the practice.

Occasionally someone will audit GPs to see if we are referring or testing appropriately, but everyone agrees that it is a balancing act, and almost all tests and referrals can be justified.

Our patients are getting older, sicker and more complex, and costs are rising due to that. We keep trying to do more with less, but what we do is still pretty damn good most of the time.

Inmara

Very reasonable approach, and good for patients who can get necessary referrals as they need. I’ve heard mixed messages about NHS from Latvian emigrants – some love it, some say it’s worse than at home. Many come to Latvia to get yearly check-ups or dental work (easy to pay out of pocked with UK salary) and even to give birth but the latter probably has more to do with support network not maternity care.

Christina Maxwell

It is absolutely NOT better in Scotland, certainly not on the East Coast or in Glasgow anyway. It is a clusterf*ck unless you are lucky.

DaisyGrrl

I don’t think this is strictly a socialized health care problem. If I understand, the NHS also has to pay damages when its hospitals are found to be at fault in a patient injury/death and that is taking up an ever-growing part of the maternity care pie. Not to mention, they should also be able to easily track lifetime expenses for babies who suffer birth injuries and women who suffer pelvic damage and compare it against the costs of more OB consultants and more c-sections.

I really think this is ideologically based thinking, kind of like the whole “breast is best” push. There’s no evidence it works, but the policy makers focus so narrowly on what they view as an ideal process that they are blinded to the bigger picture.

DiomedesV

And this is exactly why I am uncomfortable with socialized medical care.

My insurance company is concerned about their bottom line. How they determine their bottom line may be problematic. They may focus too much on short-term benefits vs. long-term benefits. We may need legislation to mandate a certain level of preventative care.

But as far as I know, my insurance company does not have an overt ideology that is driven by cultural and social forces.

It gets more complicated than that in the US, of course, because many companies (like Catholic universities, for example) are self-insured and they do have ideologically-driven policies.

The impetus to diminish of women and babies is universal among societies, and that includes the US. The potential for that to result in poor maternity care, once the government is the major provider of medical care, is really concerning to me. That is the primary reason why I do not support single-payer health care.

Who?

I’m not sure paying for yourself guarantees freedom from cultural bias. It might mean you get to choose the bias you prefer, but that won’t suit everyone and there will always be those who are marginalised.

All providers of care want to look better while spending less. Governments aren’t unique in that, the difference being they really don’t have a competitor, so have to worry less about looking good. The optimist in me thinks that some window dressing money then goes into care.

DiomedesV

Exactly. They don’t have to worry about looking good. They don’t have to compete. That is a problem.

Who?

Government can concentrate on being good, that is, do what it’s good at. ‘Good’ for a corporation is profitable. Every cent spent on a patient is money the shareholders aren’t getting. Every one.

It’s an entirely different perspective.

In Australia we have seen many utilities and services privatised, all with the promise that competition will bring enhanced accountablility, better service and lower prices. Leaving aside the obvious that these things are mutually incompatible, what has happened is prices have gone up, shareholders who buy into the new company almost always do their money, and service goes backwards. It’s happened in health, power generation and supply, transport, telecommunications.

On the whole it has been good for government, providing cash injections and helping them hand off things people need and hate to pay for, but it hasn’t been great for consumers or shareholders.

Tiffany Aching

“Exactly. They don’t have to worry about looking good. ”
They kind of do, actually, if they want to be re elected.

DiomedesV

Not in this country.

fiftyfifty1

“But as far as I know, my insurance company does not have an overt ideology that is driven by cultural and social forces.”

You don’t consider “making $$$ for our stockholders” to be an ideology driven by social forces?

Who?

Elegantly put, thanks.

It’s never clear to my why ‘shareholders=good’ and ‘citizens/subjects=bad’.

DiomedesV

I consider it more transparent.

And no, I don’t consider self-interest to be an ideology.

fiftyfifty1

I work with it every day and it really isn’t transparent at all! And it’s completely influenced by ideology. I can give a million examples but here are 3:

1. Insurance companies have to “sell” their product. So they don’t have an incentive to provide what people need, but rather what they want. Patients love, love love to get their cholesterol tested.There is no reason to test it yearly, but patients love to do so, so insurance companies pay for it 100%. If they took away that benefit, patients would be in an uproar. So we waste millions and millions yearly on cholesterol panels we don’t need.

2. Insurance companies not only “sell” themselves to patients, but also employers. Insurance companies convince employers that a “health promotion” package is what they should buy for their employees. Then as part of that, the employees need to do an expensive (and often not covered) send-out nicotine byproducts blood test to prove that they are not smokers. All the trouble and expense falls on the patient. And there is exactly zero science behind it.

3. Some commercial insurances will pay for residential anorexia treatment as long as an eating disorder specialist says it’s needed. Others will pay as long as the patient meets nationally recognized guidelines. Others will pay for treatment only in the most dire circumstances, and then only authorize 3 days at a time. Also they insist upon having 24 hours to render a decision. And they close early on Fridays and won’t give an answer until Monday. So last Friday I sent home a young man with a BMI of 16 who had lost 40 pounds in the last 4 months with a number of instabilities including signs he was digesting his own liver because I couldn’t promise his working class single mom what her insurance company’s decision would be because she has the insurance known to fight admissions until the bitter end.

Oh I could go on!

Who?

I’ve just been trying to find private health insurance in Australia that will let me buy top level hospital cover, which will pay for hospital stays (not doctors, not pharmaceuticals, not investigations while there, but the room only, theatre for certain procedures and whatever staff and non prescription consumables we might need) while at the same time letting me choose to not pay an ‘extras’ premium for chiropractic, homeopathy, aromatherapy and all the other woo du jour. The ‘extras’ I do want are dental, optical, physiotherapy and podiatry.

If I want only those four ‘extras’-considered basic- I can get them, but only with mid-range or lower hospital cover. If I want high level hospital cover, I have to pay for extras insurance for products I will never, as long as I live, use.

If I then choose to use my local dentist and optometrist, who are small business people and great members of and contributors to our community, I get only a fraction of the costs back. Whereas if I go to the insurance company’s affiliated chain of optometrists, or the ‘preferred’ dentist, my treatment will be free or dramatically cheaper.

And, with all this insurance, when my daughter broke her arm last year, we ended up $4000 out of pocket to fix it. The insurance company’s response: ‘you should have shopped around for one of our preferred doctors. No guarantee that any of them would have been able to undertake the complex surgery required. Shrug.’

Yes, the free market is awesome.

DiomedesV

I agree that these are examples of a lack of transparency. But I meant that the motive (actuating self-interest) is transparent, whereas a devotion to womyn’s power and the beauty of natural labor is not. But I don’t see where the ideology comes from. A decision does not have to be based on science to be in the best interest of the insurance company and its shareholders if it increases the profits nonetheless.

Everyone–every human being, man, woman and child, is actuated by self-interest. As a society we collectively lie to ourselves and others about our motivations. I don’t expect insurance companies to behave differently, but I don’t consider every human being to be driven by an ideology of self-interest, either.

Personally, I prefer a highly regulated insurance market (e.g., Germany), which the ACA is a poor appromixation of, to single-payer health care.

The homo economicus (man actuated by self interest) is much more of a thought experiment than of an accurate description of the reality of social interactions.
Reality it is much, much more complex. There is a lot (and I mean A LOT) of data that describe the very intricate, complex, and multifactorial forces that make us act as we do, self interest certainly being one of them.
I am sorry for saying this but “self-interest is the only force that drives people” is kind of the equivalent of “women’s bodies are made to give birth” in a social sciences context. It is a fiction that help to understand certain processes but it is not an accurate, scientific description of reality.

DiomedesV

“I am sorry for saying this but “self-interest is the only force that drives people”…”

I don’t recall saying that, as a matter of fact. I said they were “actuated by self-interest.” That was not intended to state that this is the ONLY motivation that people have. However, it is the primary motive. If you wish to contradict the ascendancy of self-interest in human affairs, the burden of proof is upon you.

In fact, the phrase “women’s bodies are made to give birth” is nearly correct from an evolutionary perspective, as long as you do not infer design from “made”. From an evolutionary standpoint, human female bodies have evolved for vaginal labor to be the primary method of childbirth. “Primary” allows for an incredible amount of waste. However, there is no doubt that selection has favored women who have successfully given vaginal birth.

Both of these are accurate descriptions of “scientific reality”, where science is conducted first by framing a question using precise language. As an evolutionary geneticist, I am confident that the “scientific reality” conclusively demonstrates that, just like fruit flies, mice, and Arabidopsis, humans are *primarily motivated* by self-interest, where self-interest is understood to include inclusive fitness. If you have data that contradicts that, then present it.

Tiffany Aching

I’m not really sure why private companies would be more immune to the Zeitgeist than government appointed experts. Dr Tuteur points here a huge failure of that system (due to the intense lobbying of the RMC), but it still seems less damaging to me than being pushed towards a homebirth because you have no insurance and you cannot go into debt to have a hospital birth.
From France where we have a not perfect but really good socialized healthcare system (and a fairly healthy population too, which is certainly in part a result of good, affordable healthcare), it is really very difficult to understand the resistance against socialized healthcare. I can see the historical and cultural factors that explain this resistance, but I am also really thankful to live in a country where you can have access to skilled practitioners and efficient drugs regardless of your financial status.

Amy Tuteur, MD

They say they save money … as long as you don’t count liability payments for injured and dead babies.

Hilary

From what I understand, this is actually coming from a push towards privatizing the NHS, so it’s the opposite of a socialized health care problem.

Christina Maxwell

No. No government would dare privatise the NHS. It is, however, a wonderful stick with which to beat the government of the day.

Who?

It’s hard to deliver care across a wide spectrum of people.

Treating the most needy, who are often the least profitable and/or most expensive always ends up being left to government or churches and charities. If I were in that situation, I’d far rather the government, who I at least have a nominal say in, take care of it, rather than ideologues.

SporkParade

Every system has its drawbacks. The drawback of a private system, like in the US, is that access to regular medical care is incredibly dependent on income and you can easily go bankrupt if you come down with a major illness. In public systems, that problem nearly disappears, but the trade-off usual comes from limited patient choice. For instance, one way that the Israeli health system tries to keep costs down is by providing better coverage for cheaper treatment options. This is annoying if you have a hard-to-treat case of something, and you want to try an expensive drug that isn’t covered. But we can still see private doctors and get private insurance if we aren’t happy about something, which is better than the Netherlands, where you literally need the permission of your assigned midwife to see an OB.

namaste863

I’m going to argue that this whole business with shitty maternity care, and please don’t get me wrong, it’s completely shitty, is a symptom of a larger problem. It indicates to me that society at large views women as expendable. We are valued only for our ability to produce males, but our lives have no real worth independently of that. And sickeningly, we are finding that if it is cheaper to let us die, the healthcare system will do exactly that.

CSN0116

Ahhh, yes. Agree. But peppering in women making other women place moral value on the way they birth their babies, coupled with the pseudoscience that “natural anything is always best” – leaves a killing field of willing victims. Like shooting fish in a barrell.

Isilzha

And if women’s lives don’t matter then their time, discomfort, dreams, and goals certainly don’t. That’s the part that always gets me with pregnancy, breastfeeding, and motherhood–it’s all about the baby. No man is ever set to this standard. He can work, not change diapers, be a mostly absent father, but that’s OK and he’s still praised for it. But a woman who doesn’t put her kid(s) ahead of her needs 100% of the time? Can she really call herself a mother!?

Who?

I’m not sure it’s as straightforward as that.

Pregnancy and childbirth are ‘natural’ events. Set the ball rolling and the outcome, one way or another, will be a baby, unless something goes wrong. Because we live in this privileged time and place, it is rare that something goes wrong. Medical staff aside, most of us might know one or two people who have had stillbirths or major complications of pregnancy.

So, it is easy to fall into the trap of thinking that this whole thing works pretty well on its own. That we’re overspending on a natural process, that we’re interfering where interference doesn’t really do much good.

Our system is now based on getting the most for your money, particularly where service is part of the picture-in healthcare, aged care, child care, the desire is to squeeze the value out of all money spent. If you want to bug everyone’s house, or go and bomb someone else, that’s a different story, but I digress.

My guess is the money will continue to flow more and more slowly until the deaths or damage are so gross that they can no longer be ignored. Then the lessons about prenatal care, monitoring and care during delivery, and the need for cs will be relearnt.

Roadstergal

“My guess is the money will continue to flow more and more slowly until the deaths or damage are so gross that they can no longer be ignored.”

Considering how gross they are already, and were known to be before this recommendation, I have to wonder just how bad it has to get.

Who?

Not a cheering thought.

Dr Kitty

I’d happily not see a midwife or GP routinely during or after pregnancy, dip my own urine, measure my own BP and SFH, palpate my own uterus and auscultate FH myself if I could use my £3000 to pay for eHarmony screening, good quality 12 and 20 week ultrasounds, a third trimester BPP, and an ERCS no later than 39w0d.

No?
Is that not what they meant by women being in control of how the money allocated to their care is spent?

AA

Who needs ultrasounds when you could hypnobirth?

Montserrat Blanco

Great idea! Let´s do that!!!

mmmmm I´m guessing you have not made the right choice so you might actually not be able to pay for that…

Roadstergal

It’s like Choose Your Own Adventure. A very limited number of specific choices.

Who?

In Australia, eHarmony is a dating website.

I take it it’s something different in the UK?

Megan

I think she means the Harmony non-invasive prenatal testing:http://www.ariosadx.com
Our practice uses a similar test, the MaterniT21. It is done at the end of first trimester to screen for genetic abnormalities like trisomies (Downs, Edwards, etc.)

Who?

Makes more sense. It just caught my eye, since they advertise a lot on tv about their scientific method of finding the perfect match.

mythsayer

What’s the money used for then? Just “treatments”? You don’t get to choose what services you want?

What if you go to the hospital? Does that net you any of those things you mentioned (if you choose the hospital route instead of the money)?

Madtowngirl

I’d never thought I’d say this, but I’m so glad I don’t live in the UK right now.

BeatriceC

Back when I worked for a major US bank, I had the opportunity to transfer to their London office. I declined on account of the horror stories I’ve heard in my old support groups for the bone condition my boys have regarding access to care.

AA

Great, personal maternity budgets can be used for independent midwives like this practice:

I will never understand giving birth in front of children. I just don’t get it.

demodocus

*unless going into very precipitous labor when the only other person home is the small child…

BeatriceC

I haven’t had time to fully read your post (I generally read through them two or three times before I comment), but I did want to point out that this paragraph is repeated:

“If the problem is that midwives are failing to use lifesaving interventions, promoting homebirth where midwives could not possibly be farther away from life saving interventions is likely to lead to MORE mistakes and MORE deaths.”

Charybdis

Maybe for emphasis?

Gatita

Beatrice, I thought of you yesterday because I saw a green parrot and a cockatiel in a too-small cage in someone’s front yard. They looked pretty happy, though, chattering away at each other and the parrot spoke some English. I hope that was just the cage they use to let them get outdoor time and not their full time home.

BeatriceC

It’s probably an outdoor cage. We have travel cages that are much, much smaller than the normal cages for the various birds.

Amy Tuteur, MD

Dr. Amy Tuteur is an obstetrician gynecologist. She received her undergraduate degree from Harvard College in 1979 and her medical degree from Boston University School of Medicine in 1984. Dr. Tuteur is a former clinical instructor at Harvard Medical School. She left the practice of medicine to raise her four children. Her book, Push Back: Guilt in the Age of Natural Parenting (HarperCollins) was published in 2016. She can be reached at DrAmy5 at aol dot com...
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